Full Access: Interview with Dr. Stacy Trooskin

With the advent of antiretroviral drugs, a cure for hepatitis C has been available for six years, but who can actually access this lifesaving, and expensive, treatment has been a battle fought out in courts and legislatures. One group that’s been, in many cases, on the losing end of that battle is the incarcerated.

But in Pennsylvania, that’s set to change. Late last year a legal settlement filed in federal court for the Eastern District of Pennsylvania will provide direct-acting antiviral drugs to 5,000 incarcerated Pennsylvanians with the hepatitis C virus (HCV). Access to this treatment, beginning with the most advanced cases and extending to everyone with HCV in prison by mid-2022, will make HCV care in Pennsylvania prisons better than what’s available to people on Medicaid in some states.

The ruling results from a four-year-long class-action lawsuit filed on behalf of inmates who were denied HCV treatment for years until their health deteriorated. Plaintiffs alleged that corrections violated their rights under the Eighth Amendment prohibition of cruel and unusual punishment.

I spoke with Stacey B. Trooskin, MD, PhD, MPH, director of the Viral Hepatitis Program at Philadelphia FIGHT and a professor at the University of Pennsylvania’s medical school, and asked her what this ruling means for those in corrections with hepatitis.

Dr. Stacy Trooskin: This is an important settlement because it means persons incarcerated in Pennsylvania will receive the current standard of care. It’s also important for public health. If we are going to eliminate hepatitis C as the health issue that it is, we must offer treatment for those living with the virus and for people who are at high risk of transmitting the virus. In this country drug use is criminalized, and for that reason, in prisons there is a disproportionate number of people with substance abuse disorder.

Pennsylvania corrections rationed care for the plaintiffs, meaning they would only treat them when they got really sick. Is this a common approach?
It varies on the type of facility, federal or state. There is the Federal Bureau of Prisons with guidelines, but state prisons often adopt their own guidelines. The one thing many correctional facilities have in common is not to adhere to the current standard of care, which is to offer a cure to those with hepatitis C.

What you are likely to see is rationing of medication and a strict set of criteria they have to meet in order to be eligible for treatment. For example, they may have to have evidence of advanced liver disease or substantial scarring to the liver. They may have to meet requirements such as abstaining from drug use or tattoos or sex, which in a prison setting may not be consensual.

Moving beyond the prison setting, what are you seeing in the population locally?
Philadelphia, like much of the country is in the middle of an opioid epidemic. We have a whole new generation that is getting infected. We know that after one year of injecting drugs, thirty percent will become infected (with HCV), and after five years as much as seventy percent will be infected.

What’s being done to prevent new infections?
Needle and syringe exchange and harm reduction programs are a necessary part of hep C prevention and reinfection prevention. In Philadelphia we have an amazing organization called Prevention Point Philadelphia, or PPP, and they do an extraordinary job making sure people have access to clean syringes and other services for people with substance abuse disorder. Nationally we need to see a major scaling up of harm reduction programs and needle exchange access. Not every place is as lucky as Philadelphia. There is PPP in Pittsburgh, but in the state, nothing else sanctioned or funded.

Can providers do more in terms of prevention?
As providers, it feels better to shake our fingers and say “you should never use drugs,” but they already know that. We need to make them understand that they shouldn’t reuse or share a cooker or cotton or water that a partner used to prepare a hit. We try to provide some of that information to keep our patients safe. Many times the providers don’t have all of that information. We need additional education for providers so that they understand the exact steps of drug use that put patients at risk.

Every drug treatment program in the country should test people for hepatitis C. Here, for every new patient it’s part of the initial labs that they get an HIV test and a hepatitis test, so we can ensure nobody is missed. We encourage other providers to look at ways of meeting those CDC recommendations.

Larry Buhl is a multimedia journalist, screenwriter, and novelist living in Los Angeles. Follow him on Twitter @LarryBuhl.

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